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PubMed1999

Moving from policy to practice in curriculum change at the University of Virginia School of Medicine, East Carolina University School of Medicine, and SUNY-Buffalo School of Medicine.

A set of formative evaluation studies from the medical schools of the University of Virginia (UVA), East Carolina University (ECU), and the State University of New York at Buffalo (SUNY-Buffalo) portrays, in qualitative and quantitative terms, evidence of achievements and obstacles to the curricular reform supported by The Robert Wood Johnson Foundation's Generalist Physician Initiative (GPI). In this paper, innovations in the under-graduate curriculum, a specific course, and instructional strategies are examined. Individual interviews of faculty and focus groups with students assessed opinions about curricular change at the University of Virginia. Questionnaires and focus groups provided information about the impact of course changes at East Carolina University. Questionnaires completed by students provided information of the effect of modifying the instructional strategies at SUNY-Buffalo. The obstacles to implementing change at the three schools included breakdowns in the faculty's understanding and support of change, lack of skills required to implement change, and weakness in coordinating and assessing planned change. Although the GPI catalyzed changes in the content and conduct of generalist education at the three schools, many lessons were learned that are applicable to other medical schools.

Curriculum↗
PubMed2000

The primary care specialties working together: a model of success in an academic environment.

In today's environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year "doctoring" curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCI's generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.

Academic Medical Centers↗
PubMed2001

Implications of the hospitalist model for medical students' education.

At many academic health centers, medical students in internal medicine, family medicine, and pediatrics are working with a new form of attending physician, the hospitalist. Although a growing literature demonstrates the benefits of hospitalists for patients and housestaff, the influence of hospitalists on students has been underemphasized. Advantages of the hospitalist model for students can include hospitalists' expertise in general inpatient medicine, their availability to teach throughout the day, and their role-modeling of the provision of high-quality and efficient care. However, the change in the ward attending workforce from non-hospitalist generalists, subspecialists, and biomedical researchers to generalist-hospitalists potentially limits students' exposure to the broad range of career opportunities the former group represents. The authors propose a research agenda to investigate the educational impact of the hospitalist model, suggest strategies to mitigate the limitations in students' exposures to subspecialty faculty, and recommend professional development in teaching for hospitalists to ensure that student education thrives in this new environment of inpatient medicine.

Academic Medical Centers↗
PubMed2001

What did we learn about the impact on community-based faculty? Recommendations for recruitment, retention, and rewards.

All ten schools participating in the Interdisciplinary Generalist Curriculum (IGC) Project were required to offer students significant generalist longitudinal preceptorship experiences during the first two years of medical school. Each school needed to recruit and then retain many new preceptors to meet the continued large demand. Effective recruitment was usually carried out by established community physicians and/or qualified staff coordinators. Retention of preceptors required establishing regular and succinct communications, quick response to problems, and flexible faculty development programs. For rewards, preceptors primarily requested acknowledgment and appreciation, along with tangible rewards such as decreased fees for continuing medical education and library or e-mail access. Preceptors continue to state that they teach because of the "joys of teaching" even in the current environment with increased demands for productivity. This article describes what has been learned about recruitment, retention, and rewards for community preceptors and how to maximize the positive impacts and minimize the negative impacts of teaching for community preceptors.

Communication↗
PubMed2001

Curricular change: recommendations from a national perspective.

Recommendations on future directions, funding, and organizational and curricular issues have emerged from the complexity of the Interdisciplinary Generalist Curriculum (IGC) Project. For example, future demonstration projects aimed at innovations in medical education that are funded through the contracting mechanism are recommended, and funding intended to serve as institutional leverage for demonstrating desired curricular innovations in medical education is encouraged. Funding provided to entities that can maximize influence within the institutions is recommended. Also, the period of time over which funds are provided needs to take into consideration the breadth of the impact of the funded program on the larger curriculum and the length of time needed to measure desired outcomes. Organizational findings are that multi-site projects with administrative oversight bodies should be governed by representatives of concerned disciplines who have stakes in the demonstration of the innovations in medical education, and roles of the executive and advisory committees involved in the effort need to be made explicit at the onset and revisited over time. Similarly, the role of the funder needs to be explicit. Curricular recommendations are that medical schools are encouraged to develop longitudinal generalist preceptorship experiences early in medical education for all students, regardless of their eventual career choices. Schools should anticipate that curricular innovations in the preclinical years may require modifications of the educational process in the clinical years.

Curriculum↗
PubMed2002

A thematic approach to enhance clinical content in a cell and tissue biology course.

OBJECTIVE: (1) To integrate clinical problem solving into freshman cell and tissue biology (CTB) and (2) to enhance understanding of diabetes using CTB principles to explain the etiology, management, and development of complications in terms of cell, tissue, and organ structure and function. DESCRIPTION: First-year medical students often question the need to learn detailed basic science material. Although clinical content has increased throughout basic science courses, little attempt has been made to link clinical correlations to one another or to enhance use of basic science material in clinical problem solving. The CTB course applies pertinent cell biology concepts such as cell proliferation, differentiation, migration, adhesion, and morphogenesis to tissue and organ function. Diabetes mellitus was chosen as a theme for CTB as diabetes has devastating effects on multiple tissues, and the disease has reached epidemic proportions in the United States, affecting individuals of every age and population group. Type I diabetes, presenting as ketoacidosis in a ten-year-old boy, was introduced by generalist physicians using a "grand rounds" approach. This format challenged students on the first day of medical school to diagnose a patient's problem and to explain the clinical findings in terms of anatomic, biochemical, and physiologic changes. The role of the blood/bicarbonate buffering system was the main focus of faculty-led discussion. The patient was then presented at age 25 with many diabetic complications. This stimulated discussion of the etiology of diabetes (type I versus type II), glycation, and the use of hemoglobin (Hb) A1c to monitor blood sugar control. Compliance and other aspects of diabetes management were added to the discussion. Faculty provided scientific information as necessary, and summary materials were distributed after the sessions. The interaction of a cell biologist with two generalist physicians optimized the integration of basic science with clinical problem solving. During the two semesters of CTB, the diabetes case is frequently referenced. Insulin synthesis provides the model for protein synthesis. Glycation, advanced glycation end products (AGE), and receptors (RAGE) are discussed. Other diabetes-related topics include wound healing (epithelium), basement membrane thickening (connective tissue), insulin regulation of muscle metabolism, diabetic neuropathy (neurohistology), platelet adhesiveness, glycation and HbA1c (blood), osteoporosis and Charcot joints (skeletal system), autoimmune mechanisms (cellular immunology), atherosclerosis and high blood pressure (blood vessels), diabetic nephropathy (renal), altered hepatic and gastrointestinal function, impotence (male reproductive system), and a comparison of type I and type II diabetes (endocrine system). DISCUSSION: Students have provided very positive feedback. The initial case enhanced interest in CTB, established clinical relevance, and has motivated learning and integration of materials from different parts of CTB and other courses. Other courses are now formally linking to the theme. For example, neuroscience will revisit diabetic neuropathy and retinopathy, physiology will relate ketoacidosis to acid-base balance, a human anatomy clinical correlation is being designed for transplantation surgeons to "cure" our diabetic patient with a renal-pancreas transplant. Uses of the case for introduction to clinical medicine, aspects of medical ethics, preventive medicine, and courses in pharmacology and pathology are contemplated.

Biology↗
PubMed2005

Publications and extramural activities of general internal medicine and medicine subspecialty clinician-educators: a multicenter study.

PURPOSE: Generalist clinician-educators may have more difficulty than specialists satisfying common promotion criteria (peer-reviewed publication and extramural reputation). This study compared publication rates and participation in extramural activities among subspecialist and generalist clinician-educators, and sought to determine the views of clinician-educators on the use of publication and reputation in determining their promotion. METHOD: A cross-sectional questionnaire was delivered to 526 clinician-educators identified by the chairs at ten randomly selected U.S. medical schools in 2002. RESULTS: A total of 270 clinician-educators responded. Medicine subspecialist clinician-educators reported more peer-reviewed publications than did general internal medicine (GIM) faculty (mean 26.4 versus 10.2, p < .003). Independent predictors of having a greater number of peer-reviewed publications were subspecialty membership (p < .01), less time spent in clinic (p < .01), focus of scholarship (p = .01), academic rank (p < .01), higher quartile of National Institutes of Health funding received by respondent's department (p < .01), and years on faculty (p = .03). A greater proportion of GIM faculty reported spending most of their protected time on scholarly activities less amenable to publication (p = .05). A greater proportion of subspecialists felt peer-reviewed publication should be required for promotion (p < .01), but a minority of both groups felt this should necessarily entail original research. CONCLUSION: Subspecialist clinician-educators generate significantly more peer-reviewed publications than do their GIM colleagues. clinician-educators hold diverse views on the role of publication and reputation in determining their promotion.

Academic Medical Centers↗
PubMed2005

Using the PRACTICE mnemonic to apply cultural competency to genetics in medical education and patient care.

Medical education curricula increasingly are incorporating courses on cultural competency and skills development in working with ethnically diverse patient populations as well as courses on genetics and genomics. The authors support these efforts and believe the next step is integration of genetics into cultural competency programs and similarly, cultural competency into genetics curricula. In this paper, the authors describe the work of the Genetics in Primary Care Faculty Development Working Group on Cultural Competency, a federally-funded initiative to prepare generalist faculty to teach genetics as part of ambulatory education. Over a 12-month period, this team wrote a module on cultural competency and nine new clinical cases, and developed the PRACTICE mnemonic (prevalence, risk, attitude, communication, testing, investigation, consent, empowerment) to help health care professionals integrate cultural competency skills in genetics into primary care. More specifically, the PRACTICE mnemonic integrates information emerging from experts in health disparities and doctor-patient communication to build a comprehensive model for addressing the relevance of culture and ethnicity in the delivery of genetic services. Lastly, this paper illustrates a systematic method of covering key areas of cultural competency through discussion of a patient with a genetic disorder as well as presents an argument as to why cultural competency is highly relevant to the delivery of genetic services especially as part of generalists' clinical practice.

Attitude of Health Personnel↗
PubMed1997

Health services research.

Advances in rheumatologic arthritis health services research continue to be of interest to clinical rheumatologists and arthritis researchers interested in healthcare delivery and policy. Recent studies have shown that a higher incidence of osteoarthritis and functional disability among rural inhabitants influences delivery of arthritis care to rural areas and urban-rural variations in specialist distribution. In the United States, managed care organizations are increasingly dictating who delivers and who receives health care for arthritis. Provision of arthritis care by rheumatologists has become more discretionary and is strongly influenced by a patient's health insurance coverage. Coinciding with this trend, a higher percentage of arthritis care is being shifted to primary care providers. Based on prominent practice pattern variations, generalists have divergent knowledge and beliefs about the value of various arthritis treatments. New therapeutic programs have been proposed to better coordinate efforts between generalists and specialists. Many arthritis patients also seek alterative therapies. Of these, chiropractic care is one of the most common nontraditional therapies. Chiropractic management appears to be as cost-effective as traditional back care in certain settings.

Complementary Therapies↗
PubMed1993

Validating a compendium of goals and objectives for educating CNS students in ambulatory care.

In fall 1990, the Department of Veterans Affairs launched a Pilot Ambulatory Care and Education program that has as its major goal the shift from a traditional inpatient specialty-based focus of patient care and health professional education to a more forward-looking outpatient generalist-based focus of care and education. The generalist and specialist focus of the CNS role has been introduced in this innovative ambulatory care program. Formal and informal educational opportunities for interdisciplinary team members and students abound. This article describes the development and validation of a compendium of goals and objectives for educating CNS students in ambulatory care.

Ambulatory Care↗
PubMed1984

The use of preventable adverse outcomes to study the quality of child health care. A new application of case-control research.

Because cohort methods are insensitive in detecting rare outcomes, the authors used the more sensitive case-control technique to investigate whether pediatricians or nonpediatric generalists are better able to recognize severe acute illness or to avoid preventable complications. We selected "indicator" outcomes for four types of common acute illness and enrolled patients who had contacted a physician more than 24 hours prior to an index emergency room visit for the same illness. Case (N = 103) were patients with adverse outcomes, i.e. potentially preventable complications or delayed diagnosis, treatment, or referral. Controls (N = 103) were those with acceptable outcomes (uncomplicated illness or prompt diagnosis, treatment, or referral) and were matched according to age, SES, and illness type. The overall results indicate no evidence of better care by pediatricians: prior contract with a pediatrician was associated with an estimated relative risk (omega) of adverse outcome of 1.32 (95% confidence interval, 0.76-2.29). Within the two largest illness categories (gastroenteritis and pneumonia-respiratory), the results were similar: omega = 1.16 (0.68-1.99) and 2.23 (0.82-6.04), respectively. Potential confounders were controlled for by multiple logistic regression analysis, but omega remained virtually unchanged. Nor were the findings altered by elimination of outliers or restriction of "contact" to office visits only. The authors conclude that study pediatricians and generalists provide equivalent acute illness care to children and that the case-control method provides a feasible and highly suitable approach to the study of the quality of medical care.

Acute Disease↗
PubMed1984

The relative complexity of primary care provided by medical specialists.

Utilizing national data on patient care provided by family practitioners, general internists, and subspecialists in internal medicine, this study examines the complexity of care provided by generalist physicians versus subspecialty physicians on a disease-specific basis. Limiting the analysis to "principal care" provided by office-based physicians, the study finds the complexity of care provided by cardiologists for heart disease and by endocrinologists for diabetes mellitus to be somewhat greater than that provided by family practitioners and general internists, though the magnitude of the differences is not large. For chronic obstructive pulmonary disease, however, pulmonary disease specialists are shown to provide care that is substantially more complex than that provided by their generalist colleagues. For all disease and specialties, hospital care is substantially more complex than ambulatory care.

Adolescent↗
PubMed1985

The continuity of care provided to primary care patients. A comparison of family physicians, general internists, and medical subspecialists.

The authors compared the continuity of care that family physicians, general internists, and medical subspecialists provided to their adult primary care patients. The 40 study physicians came from large, private multispecialty practices in the San Francisco Bay Area. The three physician types did not differ significantly in the degree of continuity provided, measured by the proportion of total visits to a patient's primary provider (usual provider continuity (UPC) score). Each type provided approximately 80% of its primary care patients' visits. In contrast, the continuity scores of individual physicians ranged widely, from 57% to 98%. Proxy measures of case mix and physician expertise were found to be associated with differing UPC scores. A more detailed exploration of the subspecialists revealed that the lowest levels of continuity were afforded patients with high utilization rates who did not carry a diagnosis in their primary physician's area of subspecialty expertise. The "generalist versus subspecialist" debate assumes that a physician's training background is a major determinant of the quality of primary care delivered. This was not true in this study for the provision of one aspect of quality, a high level of continuity. If factors other than specialty or subspecialty designation are generally found to be the important determinants of continuity, isolated changes in the proportion of physicians receiving generalist versus subspecialty training may have relatively little impact on the level of continuity afforded adult medical patients.

California↗
PubMed2000

Training primary care physicians to give limited manual therapy for low back pain: patient outcomes.

STUDY DESIGN: Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice. OBJECTIVES: To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain. SUMMARY OF BACKGROUND DATA: Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training. METHODS: Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland-Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care. RESULTS: No differences were found in Roland-Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%; P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days; P = 0.02). CONCLUSION: Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.

Disability Evaluation↗
PubMed2006

Niche breadth and geographical range: ecological compensation for geographical rarity in rainforest frogs.

We investigated the relationship between diet specialization and geographical range in Cophixalus, a genus of microhylid frogs from the Wet Tropics of northern Queensland, Australia. The geographical ranges of these species vary from a few square kilometres in species restricted to a single mountain top to the entire region for the widespread species. Although macroecological theory predicts that species with broad niches should have the largest geographical ranges, we found the opposite: geographically rare species were diet generalists and widespread species were diet specialists. We argue that this pattern is a product of extinction filtering, whereby geographically rare and therefore extinction-prone species are more likely to persist if they are diet generalists.

Animals↗
PubMed2001

Weeding and grooming of pathogens in agriculture by ants.

The ancient mutualism between fungus-growing ants and the fungi they cultivate for food is a textbook example of symbiosis. Fungus-growing ants' ability to cultivate fungi depends on protection of the garden from the aggressive microbes associated with the substrate added to the garden as well as from the specialized virulent garden parasite Escovopsis. We examined ants' ability to remove alien microbes physically by infecting Atta colombica gardens with the generalist pathogen Trichoderma viride and the specialist pathogen Escovopsis. The ants sanitized the garden using two main behaviours: grooming of alien spores from the garden (fungus grooming) and removal of infected garden substrate (weeding). Unlike previously described hygienic behaviours (e.g. licking and self-grooming), fungus-grooming and garden-removal behaviours are specific responses to the presence of fungal pathogens. In the presence of pathogens, they are the primary activities performed by workers, but they are uncommon in uninfected gardens. In fact, workers rapidly eliminate Trichoderma from their gardens by fungus grooming and weeding, suggesting that these behaviours are the primary method of garden defence against generalist pathogens. The same sanitary behaviours were performed in response to the presence of the specialist pathogen Escovopsis. However, the intensity and duration of these behaviours were much greater in this treatment. Despite the increased effort, the ants were unable to eliminate Escovopsis from their gardens, suggesting that this specialized pathogen has evolved counter-adaptations in order to overcome the sanitary defences of the ants.

Animals↗
PubMed2005

Speciation: more likely through a genetic or through a learned habitat preference?

A problem in understanding sympatric speciation is establishing how reproductive isolation can arise when there is disruptive selection on an ecological trait. One of the solutions that has been proposed is that a habitat preference evolves, and that mates are chosen within the preferred habitat. We present a model where the habitat preference can evolve either by means of a genetic mechanism or by means of learning. Employing an adaptive-dynamical analysis, we show that evolution proceeds either to a single population of specialists with a genetic preference for their optimal habitat, or to a population of generalists without a habitat preference. The generalist population subsequently experiences disruptive selection. Learning promotes speciation because it increases the intensity of disruptive selection. An individual-based version of the model shows that, when loci are completely unlinked and learning confers little cost, the presence of disruptive selection most probably leads to speciation via the simultaneous evolution of a learned habitat preference. For high costs of learning, speciation is most likely to occur via the evolution of a genetic habitat preference. However, the latter only happens when the effect of mutations is large, or when there is linkage between genes coding for the different traits.

Adaptation, Biological↗
PubMed2005

The effect of host heterogeneity and parasite intragenomic interactions on parasite population structure.

Understanding the processes that shape the genetic structure of parasite populations and the functional consequences of different parasite genotypes is critical for our ability to predict how an infection can spread through a host population and for the design of effective vaccines to combat infection and disease. Here, we examine how the genetic structure of parasite populations responds to host genetic heterogeneity. We consider the well-characterized molecular specificity of major histocompatibility complex binding of antigenic peptides to derive deterministic and stochastic models. We use these models to ask, firstly, what conditions favour the evolution of generalist parasite genotypes versus specialist parasite genotypes? Secondly, can parasite genotypes coexist in a population? We find that intragenomic interactions between parasite loci encoding antigenic peptides are pivotal in determining the outcome of evolution. Where parasite loci interact synergistically (i.e. the recognition of additional antigenic peptides has a disproportionately large effect on parasite fitness), generalist parasite genotypes are favoured. Where parasite loci act multiplicatively (have independent effects on fitness) or antagonistically (have diminishing effects on parasite fitness), specialist parasite genotypes are favoured. A key finding is that polymorphism is not stable and that, with respect to functionally important antigenic peptides, parasite populations are dominated by a single genotype.

Animals↗